Frequently Asked Questions

Medicare is federal health insurance primarily for people age 65 and older, some younger people with disabilities, and people with End-Stage Renal Disease (ESRD) or ALS. You generally qualify for premium-free Part A if you or your spouse worked and paid Medicare taxes for at least 40 quarters (10 years). Part B is available to anyone who qualifies for Part A, for a monthly premium.

Your first chance is your 7-month Initial Enrollment Period (IEP): the 3 months before, the month of, and the 3 months after your 65th birthday. Signing up in the first 3 months ensures your coverage starts the first day of your birthday month with no gap. Delaying past your IEP can trigger lifelong late-enrollment penalties.

Medicare is a federal program mostly for people 65+ regardless of income. Medicaid is a joint federal-state program for people with limited income and resources, regardless of age. They are separate programs but work together — people who qualify for both are called "dual eligibles" and usually get the most generous coverage.

Only if you are already receiving Social Security or Railroad Retirement Board benefits at least 4 months before your 65th birthday — in that case you're enrolled automatically in Parts A and B and your card arrives in the mail. Otherwise, you need to sign up yourself at ssa.gov/medicare.

You qualify for Medicare after receiving Social Security Disability Insurance (SSDI) for 24 months. People with ALS qualify the month their SSDI benefits begin, with no waiting period. People with End-Stage Renal Disease (ESRD) generally qualify on a faster timeline tied to their dialysis or transplant start date.

Most people pay no premium for Part A. In 2025, the standard Part B premium is $185/month. Adding a Part D drug plan averages about $46.50/month. A Medigap Plan G in Texas averages around $150/month. A typical Original Medicare + Part D + Medigap combo lands near $380/month before IRMAA.

The standard 2025 Part B premium is $185 per month. Higher-income enrollees pay an additional IRMAA surcharge on top of this amount, ranging from $74 to $443.90 extra per month depending on income bracket.

IRMAA stands for Income-Related Monthly Adjustment Amount. It's an extra charge added to your Part B and Part D premiums if your modified adjusted gross income exceeds $103,000 (individual) or $206,000 (joint). IRMAA is based on your tax return from two years prior — so 2025 IRMAA uses your 2023 income.

Yes. Medicare Savings Programs (MSPs) can pay your Part B premium and cost-sharing if your income is limited. Extra Help (the Part D Low-Income Subsidy) covers drug plan premiums and caps copays at just a few dollars. Your state Medicaid office or SHIP can screen you for both.

Original Medicare generally does NOT cover routine dental, vision, or hearing care. Many Medicare Advantage plans include limited benefits for each. If you stay on Original Medicare, you can buy a standalone dental or vision plan, or pay out of pocket.

Original Medicare doesn't cover most outpatient prescriptions. For drug coverage, you need either a standalone Part D plan alongside Original Medicare, or a Medicare Advantage plan that bundles drug coverage (MA-PD). Enrolling in Part D when you're first eligible avoids a lifelong late-enrollment penalty.

No. Medicare does not cover long-term custodial care — the kind of help many older adults need with daily activities like bathing, dressing, or eating. Medicare only covers short-term skilled nursing (up to 100 days) after a qualifying hospital stay. Long-term care insurance or Medicaid typically covers ongoing custodial needs.

Medicare covers dozens of preventive services with zero cost-sharing: an annual wellness visit, flu and pneumococcal vaccines, mammograms, colonoscopies, diabetes screening, cardiovascular screening, depression screening, and tobacco cessation counseling. You must see a Medicare-approved provider to get the $0 price.

The Annual Enrollment Period (AEP) runs October 15 through December 7 every year. During AEP, you can join, switch, or drop a Medicare Advantage plan or a Part D drug plan. Changes take effect January 1 of the following year.

If you miss your Initial Enrollment Period, you may have to wait for the General Enrollment Period (January 1 – March 31) and face a lifelong Part B late-enrollment penalty of 10% for each full 12-month period you delayed. Part D has a separate penalty of about 1% per month delayed, added to your premium for life.

Usually only during specific windows: the Annual Enrollment Period (Oct 15 – Dec 7), the Medicare Advantage Open Enrollment Period (Jan 1 – Mar 31, for current MA members), or a Special Enrollment Period if you qualify for one.

A Special Enrollment Period (SEP) lets you enroll or change plans outside normal windows after certain life events: moving out of your plan's service area, losing employer coverage, qualifying for Extra Help or Medicaid, or moving into or out of a nursing home. Most SEPs give you 2 months from the triggering event to act.

Original Medicare (Parts A + B) is administered directly by the federal government. It lets you see any provider nationwide that accepts Medicare, and it pairs with a standalone Part D drug plan and often a Medigap supplement. Medicare Advantage (Part C) is run by private insurers that contract with Medicare — typically lower premium, narrower network, and bundled drug coverage.

Yes. You can switch during the Annual Enrollment Period (Oct 15 – Dec 7) or the Medicare Advantage Open Enrollment Period (Jan 1 – Mar 31) if you're currently in an MA plan. One warning: if you later try to buy a Medigap policy, insurers may require medical underwriting unless you're within a guaranteed-issue window.

No. Medigap (Medicare Supplement) only works with Original Medicare. In fact, it's illegal for anyone to sell you a Medigap policy while you're enrolled in a Medicare Advantage plan. Medicare Advantage plans have their own built-in cost-sharing structure with an annual out-of-pocket maximum.

Use medicare.gov/plan-compare and enter the names of your current prescriptions along with your preferred pharmacy. The tool shows estimated total annual cost (premium + copays) for every Part D plan in your ZIP code. Compare on total cost, not just premium — a cheap plan with bad drug coverage often costs more overall.

The donut hole was a coverage gap in Part D where you paid significantly more after hitting an annual spending threshold. Starting in 2025, the Inflation Reduction Act eliminated it entirely — Part D plans now have a $2,000 annual out-of-pocket maximum for covered drugs, after which you pay nothing for the rest of the year.

Extra Help (also called the Low-Income Subsidy or LIS) is a federal program that pays your Part D premium and reduces copays to just a few dollars per prescription. In 2025, individuals earning under about $22,590 with limited resources may qualify. Apply free at ssa.gov/medicare/part-d-extra-help.

Yes, if you have creditable coverage from a current employer with 20 or more employees. You can delay Part B penalty-free and enroll later during an 8-month Special Enrollment Period after your employer coverage ends. If your employer has fewer than 20 employees, their plan is NOT creditable coverage and you should enroll in Part B at 65.

At employers with 20 or more employees, the group health plan pays first and Medicare pays second. At smaller employers, Medicare pays first — meaning you need Part B to avoid coverage gaps. Ask your HR department which scenario applies to you before deciding whether to delay Part B.

Texas's State Health Insurance Assistance Program (SHIP) is called HICAP — Health Information, Counseling and Advocacy Program. It offers free, unbiased, one-on-one counseling from trained volunteers. Call 1-800-252-9240 or visit hhs.texas.gov/hicap to find a counselor near you.

Most Texas ZIP codes have 30–60+ Medicare Advantage plans from carriers including Humana, UnitedHealthcare, Aetna, WellCare, Cigna, and Blue Cross Blue Shield of Texas. Specific plans and provider networks vary by county. Use medicare.gov/plan-compare with your ZIP to see every plan available to you.

Texans with limited income and resources may qualify for both Medicare and Texas Medicaid ("dual eligible"). Medicaid can cover Medicare premiums and cost-sharing, long-term care, and some services Medicare doesn't cover such as routine dental. Apply at yourtexasbenefits.com or through your local HHSC office.